What Changed My Mind on the Individual Mandate

March 26, 2017

The death of the GOP’s quixotic attempt at an Obamacare
replacement is surely cause for some relief, not only for Democrats but, more
importantly, for all those whose health care would have been genuinely at risk,
as well as the growing number of professional organizations publicly expressing
alarm at a bill that seemed designed to gut the parts of the Affordable Care
Act that were actually doing some good rather than amending its flaws. Indeed, the very idea that the ACA needs
amending has long been buried beneath the polemic between those seeking to
either repeal or defend it at all costs.
Now that it remains in place “for the foreseeable future,” the tone of
the polemic appears to be shifting only slightly, with defenders still blindly
refusing to admit to any problems with it, and detractors hoping to wait out
(and urge on) its self-destruction just for the chance to say “told you so.”

With a view to reviving nonpartisan examination of what is
both right and wrong with the ACA, I offer here my own critical reflection on one
aspect of it that I myself have come to rethink – not from the perspective of a
policy wonk or an insurance expert, of which I am neither, but that of a
language service provider who has had occasion to witness a sampling of
particular situations in which the positive and negative effects of the ACA are
manifest. Working as a telephonic
interpreter, I have gone through countless applications to the federal health
insurance Marketplace, as well as phone calls to various insurance companies
from US nationals (naturalized citizens and green card holders in this context)
with limited English proficiency. In a
health care system that can be difficult to navigate even in one’s native
language and culture, the need to do so with the help of interpreters and
translated materials only adds to the complications that many have faced when
trying to sign up for – or keep – health insurance.

One of the ACA’s more controversial points has been its
“individual mandate” requiring individuals to purchase health insurance or pay
a penalty on their tax returns. Defenders
of the mandate argue that those with the health and financial means to have
less immediate need of health care have a responsibility to pay into the
insurance market in order to keep the cost affordable for those who need it
most. I’ve generally found this point
persuasive, and I cannot agree with objections based merely on personal choice,
as if anyone’s choice were worth more than anyone’s life. At the same time, lost in the debate between
individual choice and the common good are the many people who fall through the
cracks within a deeply flawed system. Having
been largely convinced of the merits of the mandate as a step toward universal
health care, observing multiple instances of people being failed by the system
has given me pause.

Many cases I’ve heard confirm the reports of skyrocketing
costs. In some of these cases it is the
insurance companies raising premiums, sometimes without warning, which can be
devastating for someone living paycheck to paycheck. But the premiums themselves are not the only
culprit. Often, people may unexpectedly
lose the tax credits they had received through ACA subsidies, for a number of
reasons. One of the most frequent
reasons is documents not ending up in the right place, which happens
disturbingly easily if any detail is off, as I’ve heard in a surprising number
of conversations about documents being resent and re-requested multiple times.

In other cases, people may experience what in Obamacare’s parlance
is termed a “qualifying life event” – for example, a change in one’s state of
residence, income, family size, or marital status, which would qualify them for
a special enrollment period to purchase insurance outside of the designated
“open enrollment” – without knowing that they have a limited time frame after
the change occurs in which to do so.
Some people have simply made do with hospital sliding-scale payment
systems, which allow them to get the care they need, only to discover that they
still don’t meet the insurance requirement.
In the above situations, the lack of adequate and timely information,
including frequent lapses in communication and responsibility between the
Marketplace and insurance companies, appears to be a widespread problem in
general, which of course is only exacerbated when there is a language barrier.

Still others simply find themselves in an awkward gap in
which, between their actual incomes and living expenses, rising premiums, and
the mysterious machinations of the Marketplace’s tax credit calculus, they
still end up without any insurance options they can actually afford – and are
penalized for it. The system ends up
being especially punitive toward people who are legally married but separated
from their spouses, whether due to estrangement or practical necessity. People in these situations often find
themselves in a double bind, since they are disqualified from receiving a tax
credit if they don’t file taxes jointly but may still qualify to purchase
insurance they can’t afford, leaving them fined as well as uninsured.

To complicate matters further, in states where legislators
have chosen not to expand Medicare and Medicaid services, people who qualify
for low-cost insurance they can’t receive are exempt from the fine, but still
left without insurance. This latter
situation is of course the fault of state-level politics rather than the
individual mandate, which only further demonstrates the very concrete
ramifications of the political tug-of-war that health care in America has
become.

The real problem with the individual mandate is not that it “forces”
health insurance on those in a position to choose not to buy it, but that it
too easily ends up hurting those who have difficulty affording insurance – the
very people the mandate was supposedly meant to protect.